Exploring Diagnosis Challenges in Patients with Lupus

Anne E. Winkler, MD, PhD, MACP: We all know that it's difficult to diagnose patients with lupus because we all have those patients sent to us from our primary care providers who are wonderful people but aren't as experienced in rheumatology. And they've all drawn a positive ANA of 1 to 80 and are sending them to us thinking they have some dread disease. When we think about diagnosing that, particularly in terms of clinical trials and the criteria we have developed for clinical trials in terms of lupus.

Kristi V. Mizelle, MD, MPH, FACR: The classification criteria, the American College of Rheumatology and EULAR have come up with SLE classification criteria. And they're very helpful to help us understand and think about lupus patients as a whole and what type of presentation that there may be. And to also help give us some rubric to concretely outline what are the things that speak to potentially a lupus diagnosis? What I will say is that clinically when I see patients who have lupus who've had it for a long time and they were diagnosed by someone else, I always think back and reconfirm diagnosis for myself. Unfortunately, before we had these classification criteria to help us in thinking through individual patient diagnoses, patients who had all over pain and even a low titer ANA were called lupus which is probably not the patient population that we're looking at or think of clearly as a lupus diagnosis. I will always reclassify myself to make sure that I understand and feel comfortable that the diagnosis is clear. There may be misdiagnosis particularly when I mentioned older ways of looking at lupus and making a diagnosis and ANA plus any symptom which could be fatigue or a little bit of joint pain but without inflammatory arthritis was called lupus. I call that old-fangled rheumatology. But new-fangled rheumatology thinks about it more objectively but there is still an art to making the diagnosis. And the ACR/EULAR criteria from 2019 helps us in thinking through individual patient diagnoses. However, they're not necessarily created for individual patient diagnosis we can extrapolate and use that rubric to help us in making the decision as to whether a patient has lupus. But there is also somewhat of an art as well because we must be a bit a detective when we think about if a patient does have lupus. It's not just do they have an ANA but do they have an ANA and what titer? Also, what other clinical manifestations are there, what other laboratory evaluation of positives that speak to lupus. Then we put all of that together and when we do that the picture may become one more of lupus. And so there's definitely something to be said for patient, people who have been doing this for a while and putting together this because it's almost like a clinical acumen that develops as you develop your ability to practice. Not just the scientific but the art part of rheumatology. It's definitely an interesting place to exist in that rheumatology is advancing so much and becoming much more standardized in our approach but they're still of those things like that clinical gut feeling also the subtle things that will make you lean towards the diagnosis.

Transcript Edited for Clarity